pain and comfort

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Chapter 27

Pain and Comfort

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described as such”

Nociceptive pain

Neuropathic pain (Box 27-1)

All pain is multidimensional with sensory, psychosocial, emotional, personal, and spiritual components

Pain is categorized as either acute, or chronic and persistent

Nociceptive comes from actual injury to organs—arthritis, ulcers, heart attack, etc and is often described differently from

Neuropathic pain that arises from damage/changes to peripheral nerves and is often described as burning, itching

Pain and Comfort

As one ages, acute pain occurs most often superimposed on the persistent pain of preexisting chronic pain

The most common type of pain in late life is persistent

Persons with persistent pain are more likely to be depressed and to have sleep disorders, but not all who are depressed have physical pain

Inadequately treated persistent physical pain will almost always lead to impaired functional status and in some cases cognitive impairments (Box 27-3)

And this can lead to decreased quality of life and downhill trajectory!

Pain in the Older Adult

More men than women report pain

Barriers to pain management in the older adult (Box 27-4)

Potential impact of persistent pain (Box 27-5)

With aging there is a decrease in density of both myelinated and unmyelinated nerve fibers very slightly delaying sensation of pain from the periphery and there is slower resolution once triggered

We discussed these in Pharm—barriers can come from everyone involved in the interaction and we as nurses need to be aware of them and

Address them so patients have appropriate pain management!

Consider what it means to have chronic pain

Can’t sleep—exhausted during the day, further limiting my independence

Don’t enjoy activities because of the painlose healthy activities and interaction with others

Consider how the person will evaluate chronic pain management—it is best to look for goals that are important to the patient, instead of just a number

”I consider my pain managed when I can play with my grandchildren”

”It is important to me to be able to play a round of golf with my old squadron mates”

Etc—what does the pain mean to the patient?

COMFORT GOAL (pg 335)

Pain in Older Adults With Cognitive Impairments

Persons with cognitive impairments are consistently untreated or undertreated for pain

Older adults who are cognitively impaired receive less pain medication, even when they experience the same acutely painful events

Providing comfort requires careful observation of behavior and attention to caregiver reports and knowing when subtle changes have occurred

Pain cues in persons with communication difficulties (Box 27-6)

Look for

Changes in behavior

ADL’s—is there a change?

Vocalizations

Physical changes

Promoting Healthy Aging: Implications for Gerontological Nursing

Pain management is that in which both pharmacological and nonpharmacological interventions work in harmony

The basic approach considers what has worked in the past and been effective without causing harm

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment

A high-quality comprehensive instrument incorporates the most important aspects of assessment and includes person’s self-report, and both qualitative and quantitative measures of comfort

Pain diary

OLD CART

Assess for coexisting depression and anxiety

Pain Diary

Location of pain

What was happening/being done at time of pain

Medication taken

Any other treatment/intervention

Intensity of pain

Intensity of pain an hour after interventions

OLD CART

ONSET

LOCATION

DURATION

CHARACTERSITICS

AGGRAVATING FACTORS

RELIEVING FACTORS

TREATMENTS

Iatrogenic pain—pain related to treatments or care—turning the cancer patient with mets to the bone—adapt and individualize the care of every patient

Promoting Healthy Aging: Implications for Gerontological Nursing

Rating the intensity of pain

A key element of assessment is the intensity of pain perceived by the person; it is always what the person says it is

Rating scales have become the standard of care

Scales that are currently available and tested may not be reliable for persons with delirium or more severe impairments

Tools for comprehensive review of pain (Box 27-9)

Box 27.8 lists additional factors they may impact pain assessment

How does the pain affect function?

Does the patient use alternative expressions of pain?

Social support

Pain history

Numeric Rating Scale (NRS) and Faces Pain Scale—Revised (FPS-R)

Image of FACES pain scale with 5 faces: smiling, slightly smiling, neutral, slightly sad, very sad

Numeric pain scale of 0 (no pain) to 10 (worst pain) with 5 being (moderate pain)

For those who do not acknowledge or express pain for cultural reasons, these will not change that and will not work

Promoting Healthy Aging: Implications for Gerontological Nursing

Assessment of pain in cognitively impaired/nonverbal

Persons with impaired communication skills with noncommunicative patients (Box 27-10)

It is recommended that attempts are made to use standard assessment instruments first even when the person has advanced dementia

The Pain Assessment in Advanced Dementia (PAINAD) Scale developed for use for those who either cannot express or cannot reliably express pain (Table 27-1)

PACSLAC-2: behavioral assessment tool that may be helpful as an initial pain screen

PAINAD

Breathing

Negative vocalization

Facial expression

Body language

Consolability

PACSLAC-2

Facial expression

Verbalizations and vocalizations

Body movement

Changes in interpersonal interactions

Changes in activity patterns or routines

Mental status changes

Promoting Healthy Aging: Implications for Gerontological Nursing

Interventions: Providing comfort

Clinical manifestations are complex with multiple potential sources and sites for pain and confounding variables such as chronic disease, frailty, and depression

Nonpharmacological measures

Heat/cold

Transcutaneous electrical nerve stimulation

Acupuncture and acupressure

Relaxation, meditation, and guided imagery

Music

Activity

Cognitive-behavioral therapy

These should be used in addition to pharmacological, especially for chronic pain

Generally take more time, but improve pain management

Promoting Healthy Aging: Implications for Gerontological Nursing

Pharmacological interventions

While treatment regimens vary, all are guided by the same underlying principles (Box 27-12)

To achieve the highest level of pain control, it is helpful to ease the “memory of pain,” especially when persistent pain is intense, meaning prevent pain, not simply relieve it

ATC dosing, at the appropriate dosage

PRN for break through pain

Current recommendations are to start with the lowest anticipated effective dose, monitor the response frequently, and increase the dose slowly to desired effect: “Start low, go slow, but go!”

ATC is around the clock instead of prn—this helps to maintain that therapeutic level of drug in the body to avoid loss of

Pain relief when doses are delayed by having to request them

Promoting Healthy Aging: Implications for Gerontological Nursing

Pharmacological interventions

Nonopioid analgesics

Acetaminophen

Nonsteroidal antiinflammatories

Opioid analgesics

Tramadol, morphine, fentanyl

Adjuvant drugs

Herbal preparations, antidepressants, and anticonvulsants

Acetaminophen—remember it can impact the liver, is metabolized by the liver, excessive doses can harm the liver

Max of 3,000 mg (3 g) per day in patients who are frail or have liver or kidney disease (max for all is 4g/24 hours)

Keep in mind the effect of alcohol on metabolism of acetaminophen, so that must be taken into consideration

Although it is considered safe when used with warfarin, as it does not increase the risk of bleeding, it can affect warfarin levels, so

Monitoring of the PT/INR is essential

NSAID’s are ideal for inflammatory disorders, BUT have a high adverse effect profile

Of course most people are aware of its effect on the GI tract (blocking the positive protective effects of prostaglandins in the stomach),

So the patient must be aware of the risk of GI bleeding with chronic use

These drugs also impact the creation of prostaglandins body wide and the concern is the effect on the vasculature in the kidney—

Prostaglandins cause vasodilation-blocking prostaglandins will cause vasoconstriction decreased blood flow to the kidney

Can result in acute kidney injury, increased blood pressure, as RAAS is stimulated with decreased perfusion of the kidney

Worsening of hypertension!!!

NSAID’s OTC are ibuprofen and naproxen

Alternative

Celecoxib (COX-2 selective, so block pain causing prostaglandins, so less effect on stomach)

Give NSAID’s with misoprostol or PPI’s to decrease effect on stomach

Patches and creams are being produced in a variety of formulations that reduce systemic effects

Opioids—increase risk of falls and can produce increased adverse effects based on concurrent chronic diseases like COPD

Start low and slow, but treat pain

NO MEPERIDINE IN OLDER ADULTS (it is now used rarely in any patient, as there are safer opioids—chronic use increases risk of seizures)

Neuropathic pain often responds poorly to opioids, and better to antidepressants (SNRI’s, TCA’s) and antiseizure meds

Some use is limited to the anticholinergic side effects, especially with TCA’s, so make sure you know what is meant by anticholinergic side effects!

Cannabis has been shown to have a positive effect for some

Promoting Healthy Aging: Implications for Gerontological Nursing

Pain clinics

Provide a specialized, often comprehensive and multidisciplinary approach to the management of pain that has not responded to the usual, more standard approaches

Three types:

Syndrome-oriented

Modality-oriented

Comprehensive

Promoting Healthy Aging: Implications for Gerontological Nursing

Evaluation of effectiveness

Effectiveness of any intervention designed to relieve pain is quantitatively measured with repeated use of the intensity scale; qualitative observations are supplements to this

The nurse advocates for the person so that adjustments of treatment regimens and interventions are based on reassessment findings

“Start low, go slow, but go!”

Question 1

Which is an effective pain assessment tool?

Pain diary

FACES Pain Scale

Numeric Pain Scale

All of the above

ANS: D

Question 2

Pain is:

whatever the client says it is

what the family says it is

what the nurse observes

what the health care provider observes

ANS: A